Wednesday, October 31, 2012

Another View of the US Hospital Care System

This blog entry is not about childbirth.  But it is a blog entry about navigating the health care system.  It is also a confirmation of the statement childbirth expert Suzanne Arms made several years ago (and I paraphrase), Hospitals are not made for the individualized care of individuals, but for the mass care of the masses.

While there is much more to this story, I’ll just summarize some of the inappropriate, unprofessional and idiotic actions during a 3 day period.

Once upon a time, there was a hospitalized elderly gent (88 years old), who after a somewhat sudden revelation of anemia caused by kidney failure, subsequent installation of a fistula for dialysis, and an indwelling catheter, was scheduled to be transferred to the 3rd floor of the same hospital for rehab.  Family received a phone call around noon on a Friday, and were told the transfer to rehab would be at 5 pm that day to room 381 and to bring loose fitting clothes for the gent to ambulate in for the next 7 -10 days.

While gathering said clothes and running some errands (about 2 hours later), the family gets another call from the same rehab unit saying the gent’s admission has been denied and one of his 5 physicians has ordered him to be discharged to home at 5 pm which was in 2 hours.

Now this discharge to home had indeed been the plan all along…until the day before this Friday when it was discovered by family that the gent would need catheter irrigation every 2 hours around the clock – a procedure his 84 year old wife could not possibly do.  In fact, the family had been discussing alternative care options. 

As family members rushed to the hospital with the understanding that he was being discharged at 5 pm to go home, one family member requested that the hospital unit case worker, director of the rehab unit, social worker and patient advocate meet with the family for a brainstorming session.

During the insuing 90 minute heated conversation, the rehab director admitted they may have acted in haste in making the first call to the family about the transfer to rehab before the transfer had been approved by the rehab physician who reviews all transfers.

The rehab director’s reply, “These things happen.”

The unit case worker said that it was the family’s intention to take the gent home all along and didn’t see a problem with his 84 year old wife flushing the catheter every 2 hours x 24 hours each day.  Really?  So now that we are asking for more than 3 hours to make alternative care decisions, the family would have to be billed for any extension of his stay?  Really?

When the question came up by the family to the hospital representatives “So if the gent cannot stay in the hospital, cannot be transferred to a local nursing home (because they “don’t do” catheter irrigations), and cannot be cared for at home, exactly where is this gent to go?  A tent in the parking lot?

The hospital reps reply, “We don’t know.”

a hospital west of Indianapolis
With the rehab director repeatedly stating a prescribed script about how he cannot go to rehab and cannot stay at this hospital, the social worker now arrives to add some sanity.  But before she does, the unit case worker suggests that she can call the physician who ordered the irrigation so he can change his order for irrigation to make the gent more able to go to an alternative care facility.  Really?  Since in the past year when his catheter has only had a PRN (as necessary) irrigation order, clots formed and urine backed up which caused the kidneys to fail in the first place.

Iatrogenic?  I believe so.

Now with the first hour of the conversation complete, the social worker arrives and sheds some true light on the immediate situation:

  1. The family has now until Monday to make plans for alternative care and the social worker states that she will work tomorrow (Saturday) to assist.
  2. The family doesn’t have to incur a cost while all (including the hospital) are actively looking for care for this gent.
  3. The rehab director reminds the one emotionally exploding family member that the family member’s voice mail is full and the rehab director all the rehab director got when calling the family member was the playback music.  Not only was my voicemail NOT full but I don’t have playback music, nor did I have a missed call from her.
  4. A rehab nurse interrupts the last 30 minutes of the brainstorming session saying “I’m ready to transport him to rehab” – the rehab director wipes yet another load of egg off her face.

The rehab director either lied or is incapable of dialing a phone……or communicating with her employees.

Since then, we have also found out that the social worker does not work on the weekends and she did not do any work on this case until Monday.

Now, due to the change in the irrigation orders, the gent was discharged to home on Tuesday.

While there are more absurd situations, I will not bore you with those.  I can tell you one thing: the state of the US health care system, from birth to death, is generally not friendly to humans.  And if that is not an oxymoron, I don’t know what is.

Tuesday, October 30, 2012

Beautiful Belgian Waterbirth

From the award winning childbirth documentary Waterbirth in the 21st Century - filmed with Dr. Herman Ponette at the Henri Serruys Hospital in Ostend Belgium.

Monday, October 22, 2012

Updating Childbirth Education

A retrospective examination of childbearing trends shows that the natural childbirth movement of the 60’s and 70’s was successful due to the major contribution of education. 

But what has happened? Let’s take a look at the facts: 

 2012 vs 1970s 

Epidural rates are higher. 
Cesarean section rates are higher. 
“Natural” or physiologic birth rates are lower. 
Attendance at childbirth education classes is lower. 
Attendance at childbirth education classes, in some communities, is discouraged. 
US maternal/infant morbidity/mortality rates are some of the worst in the world. 

 A policy brief from The Center for Family Policy and Research of the Department of Human Development and Family Studies at the University of Missouri (Columbia) states that there are six major benefits of childbirth education classes: 

  • Enhances of woman’s confidence in her innate ability to give birth. 
  • Fosters positive feelings toward the birth, caregivers and the infant. 
  • Decreases the use of drugs during labor – including costly epidurals. 
  • Offers an opportunity for social support during pregnancy – leading to reduced lengths of labor and obstetrical complications. 
  • Facilitates positive birth outcomes, including reduction of cesarean births. 
  • Sets the stage for successful initiation of breastfeeding and adjustment to new parenthood. 

While little recent research exists, studies by Lederman in the 1970s (Lederman RP, Lederman E, Work BA et al: The relationship of maternal anxiety, plasma catecholamines, and plasma cortisol to progress in labor. American Journal of Obstetrics & Gynecology 132: 495, 1978) demonstrated a relationship between anxiety, maternal attitudes, plasma catecholamines, uterine contractility, length of labor and Apgar scores. Anxiety leads to an increased production of plasma epinephrine, which inhibits uterine contractility and increases length of labor. Anxiety and stress reduction are integral parts of most childbirth education class curriculum which may also include education about the anatomy and physiology of labor/birth, a myriad of comfort measures, and the importance of physical/emotional support during labor. 

What is “wrong” with childbirth education that so many benefits are not recognized by the public? Insight into this problem came from the De Vries article in 2007 (De Vries, C. & De Vries R. Childbirth Education in the 21st Century: An Immodest Proposal. Journal of Perinatal Education 2007 Fall; 16(4): 38-48.). Disconnects in childbirth education included a mismatch between what childbirth educators offered and what expectant parents wanted, cultural bias in education, and loss of community based childbirth classes (co-optation to hospital classes). If an educator is teaching the same way as in the 1970’s, then parents of today will not find their learning style with that educator. 

Educators in 2012 and beyond should examine the power of websites in education (not just pieces of static advertising), Facebook in disseminating research studies, and Twitter for sharing small but powerful bits of information. More educators should be partnering together to develop Apps for smartphones and tablets plus podcasts that can be downloaded and listened to when there is time in the busy expectant parents’ day. While some parents may be able to continue with the classroom style of education, I fear we are losing more parents by not embracing the technology at hand and trying to fit these “round” parents into our comfortable, square pegged classes.

Thursday, October 18, 2012

The Perfect Response by Barbara Harper

My long-time friend, Barbara Harper (founder of Waterbirth International), posted this on her Facebook page. I found her dialogue so phenomenal, I asked her permission to reprint.  So here it Barbara’s words….

There was a commentator on the radio in Miami this morning (10/18/12) extolling the virtues of planned cesarean surgery and induction because you can guarantee that your doctor will be there as one reason to "control" the birth of your baby. This was my response:

To the uninformed person who commented on the convenience and safety of inductions and scheduled cesarean surgery instead of waiting for the perfectly timed dance of undisturbed childbirth: 
Barbara Harper

All human beings are programmed by brain wiring and influenced by the environmental signals to initiate the birth process through a complex set of chemical, hormonal and neurological transmitters. The new human needs that process to fully engage and activate parts of the brain that contribute to health, well-being, cardiovascular stability, respiratory function, neurological development and even feelings of love and attachment. 

When we arbitrarily assign a date to chemically initiate the process, the innate programming gets shut down, cannot function in the same way as the biological imperative would have, had things been left alone. The human being perceives this "jump start" as a threat and begins to prepare its body and brain to survive in an environment that is stress filled and possibly life threatening. All of the bodily functions that control the neurological, cardiovascular, respiratory, metabolic adaptive mechanisms are put on high alert and remain there. This over stimulation of the psychoneuroimmunological system creates and lays down the patterns for future problems such as heart disease, high blood pressure, diabetes, chronic obstructive pulmonary disease and even some psychiatric disorders. 

This may be difficult for the uninformed consumer to begin to see the connections between the use of a simple drug to stimulate the uterine contractions or a surgical procedure to remove a human being from the habitat in which brain development is meant to take place, but the growing field of epigenetics and pre and perinatal psychology are rapidly filling in the gaps in our understanding that what we do in the birth process has life-long consequences on human health, the development of character, mental stability and perhaps even drug addiction. Tall order? Perhaps we are only beginning to realize the long term effects of this violation of an innate biological agenda - because that is what early chemical induction is!

As they say, "don't mess with Mother Nature!"

These scientific principals and the evidence to support this thesis are contained in my forth coming book, "Embracing The Miracle: How Pregnancy, Birth and the First Hour Influence Human Potential."  There are already many books and hundreds of research studies from which to broaden your understanding of allowing nature to fulfill its destiny in the creation of new human beings. Parenting For Peace by Marcy Axeness is a great book for any potential parent or grandparent along with my other book, Gentle Birth Choices . 

Wednesday, October 17, 2012

Ten Facts About Maternity Care You Should Know

A profession that recommends best practice care yet shuns evidence-based care is contradictory and in danger of implosion if the receivers of that care discover the contradiction.  Therefore, a combination of fact distortion and suppression of education is the key to avoiding revelation and implosion.

1.    The maternal mortality rate in the US is 12.1 deaths per 100,000 live births.  This number is greater than 40 other countries in the world. (Source: Amnesty USA Deadly Delivery: The Maternal Health Care Crisis in the USA, 2010).
2.    Cesarean sections are partly to blame for the rise in the US Maternity mortality rate. (Source: California Maternity Quality Care Collaborative, 2011).

3.    The FDA has not approved the drug Cytotec for use as an induction agent for childbirth.

4.    The US Food and Drug Administration has issued alerts about the use of vacuum extractors used during labor/birth, including fetal hemorrhage, shock and death.

5.    The Joint Commission, the body that accredits US hospitals, encourages a reduction of cesarean rates to the limit suggested by the World Health Organization ~ 15-20%. (Source: The Joint Commission Specifications Manual for Joint Commission National Quality Core Measures, 2010).

6.    “A baby born by cesarean surgery is more likely to be admitted to a neonatal intensive care unit or NICU physically separated from his or her mother, thus making establishing breastfeeding more difficult.” (Source:  Impact of Birthing Practices on Breastfeeding, 2011).

7.    Women’s birthing preferences are shaped by economic position and availability of local birthing options. (Source:  Social Science & Medicine, 2012 Aug. 75(4) 709-16)

8.    All drugs given to a mother during labor cross the placenta to the fetus/baby.   (Source: Anesthesiology 1995 83(2) 300-308)

9.    The US breastfeeding rate on initiation is 76.9% (2009), 47.2% at 6 months, and 25.5% at 12 months. (Source: CDC Report Card, 2012)

10. There are 14 risks of formula feeding infants.  INFACT Canada has a brief annotated bibliography that is in a pdf format and easy to print and give to parents and care providers.

Monday, October 15, 2012

Another Rush to Implementation? Human Breastmilk from Genetically Modified Cows

From the CDC’s mPINC  of 2009 to the Surgeon General (US) Call to Action to Support Breastfeeding in 2011 to the Healthy People 2020 targets, we are all familiar with this country’s (and global) initiative to increase health of newborns and young children through exclusive breastfeeding.  More and more hospitals are working toward and achieving the Baby Friendly Hospital Initiative (BFHI).  And while this is all good news, there is some not so good news…if a baby is not breastfed, that means the baby is formula fed.  Statistics show repeatedly that infants who are formula fed are more likely to die no matter where they live on this globe.  And the health threat isn’t only for the children.  The incidence of maternal illness in those who do not lactate are higher for situations such as postpartum depression and breast and ovarian cancers.

Just when we thought we were making headway in the world of BFHI and staff training to facilitate labor practices that promote breastfeeding, a stunning development is making the rounds again in social media: genetically modified cows produce human milk.

In 2011, scientists in China announced their success in producing a human genetic coding in the DNA of Holstein cow embryos, thus producing a herd of cows that make a milk with the same nutritional properties as human breastmilk, but with a taste even stronger and sweeter. “The genetically modified cow milk is 80% the same as human breastmilk,” said lead researcher Dr. Li Ning. At that time, over 3000 cloned cattle lived on an experimental farm in suburban Beijing, announced the researchers at the State Key Laboratory of Agrobiotechnology of the China Agricultural University.  Researchers were able to create a cow that produced milk with the human proteins lysozyme and lactoferrin.

But some interesting questions arise from this and it is the professionals who are asking. 

JH from Iowa said “On one hand, as a mother who had a horrible time breastfeeding because of low supply and an infant who was allergic to virtually every commercial formula and was unable to get donor milk, I think this COULD be a great alternative and save a lot of stress and anxiety over feeding infants quality nutrition.  However as a scientist, I am concerned about the safety of this, especially regarding future dairy allergies and what the other 20% contains.  I would want to know much more about the research and how the genetic material was obtained before making a decision one way or another.”

SD from West Virginia stated, “I’d rather see this much time and energy put into opening more human milk banks in the USA instead of worrying about striving for more GMO foods.”

AG from Wisconsin mentioned, “If it works out, and the product will make money – as long as they can keep the arsenic and such out of the cows’ diet.  People are uncomfortable with this kind of large animal cloning until they need the product it produces.  It may result in less processed milk formulas, which could be healthier for children.  It also seems like a gateway to more genetic experimentation.”

All too often in medicine, we find something potentially amazing discoveries and rush to implement them.  However, do we truly research the side effects both immediate and long term?  In many instances, we do not.  And this may be another time when we rush to implementation.

What are your thoughts?

Tuesday, October 09, 2012

Building A Curriculum: The nuts & bolts

As discussed in an earlier blog post, curriculum development is a time consuming process but one that allows the presenter to become intimately familiar with the topic AND smooth the presentation style.

If you use the form generally accepted for curriculum development (see below), this will help you with development.  With this form, you can also use the Four Steps to Curriculum Development: Planning, Developing, Implementing, and Evaluating.  In Planning, an assessment is usually done prior to development to see if there is a need for the presentation or course.  If there is a need, then the planning for content continues.  During Development, measurable objectives, timing, and teaching strategies are assessed for maximum utilization with a broad spectrum of learners.  With Implementation, the presentation is actually put into practice several times to make sure of logical flow of topics, clarity of content, and to become familiar with the content.  Evaluations can be used to project the success of the presentation and assess for updates.

Identify the first topic and select the objectives that relate to that topic.  (Planning)

Format an outline of discussion points for this topic and then practice presenting this information.  
Time yourself a few times to make sure that you are confident in the length of time it takes to complete this portion of the topic.  

Then select 1-3 teaching strategies with which to present this information. Remember you are teaching to a wide variety of learners: audio learners, doers, visual learners, and those who like to have all of the input! (Developing)

Once you have put all of the topics and objectives together in this format along with the timing and teaching strategies, you should have a solid curriculum.  If you use this presentation numerous times, reorganization and updating become part of the routine.  A great presenter never presents the same twice.  Tweeking is expected, especially in the business of maternity care where evidence based information is refined frequently! (Implementing)

One Type of Likert Scale Evaluation
Is this all there is to it, you may be asking?  No, one more element is crucial to a great curriculum and that is a great evaluation tool.  You may choose the Likert Scale as the format for your evaluation tool.  This Scale was developed by Rensis Likert in 1932 and requires the individuals to make a decision on their level of agreement, generally on a five-point scale (ie. Strongly Agree, Agree, Disagree, Strongly Disagree) with a statement. The number beside each response becomes the value for that response and the total score is obtained by adding the values for each response, hence the reason why they are also called 'summated scales' (the respondents score is found by summing the number of responses).   (Evaluating)

While we do not like to have critiques of ourselves that could be deemed as negative, an evaluation is a useful too to refine the presentation and improve it for the future.  Understand that you will not please everyone all of the time, however if the majority of the individuals find that their expectations where not met, then you may want to re-examine your objectives to hone them more to what you are presenting.

In addition to the Likert Scale Evaluation, you may also want to make available to the evaluater a few lines that they can use to put into their own words some suggestions for future presentations.  These suggestions may further improve your presentation with specific indicators.

Are you designing a curriculum for use in maternity care?  Would you like someone to take a look at it between the Development and Implementation stages?  If so, contact me at  

Monday, October 08, 2012

Building a Curriculum: Top 10 Things to Consider

Are you inspired to create a presentation?  Do you want to speak on a topic that you are passionate about but don't know where to begin?  This is the first of several basic tutorials on curriculum development adapted from the Birthsource Lamaze Childbirth Education Seminars that I teach.  

First, read through the Top 10 Things to Consider below.  If you would like a practice worksheet for this, please email me at  


In maternity care, there may be many opportunities to create courses for continuing education.  How does one begin to put together a curriculum and what are the first common steps?

Decide on Basic Topic ~ this may not take a lot of brainwork especially if you are passionate about something to begin with!

Name the Presentation ~ you may have to brainstorm on this one to get a catchy, trendy title!  Avoid sarcasm, off color remarks or inappropriate jabs at individuals/organizations.

Include speakers and their CVs/resumes ~ if more than one person is speaking, you will need to include copies of the curriculum vitae or resume.  Need more info?  Click here.

General time allotment for presentation ~ basically, how long do you have for this presentation?  Minutes? Hours? Days?

Topic list in logical order of presentation ~ first write down all of the topics you want to include in this course and then put them into a logical order.  “Logical” order may be chronological, alphabetical, or in order of appearance (as when each one builds on the previous ones).

List of teaching strategies ~ what types of strategies will be employed to get your point across to the various types of learners in your course? Make a general list.  Read about adult learners!

Define basic objectives ~ what are the basics outcomes that you would like to see students achieve?  Need more help?  Click here.

Will the students do any pre-attendance work? Any advanced reading or forms to fill out?

Required or recommended reading lists? Will there be books, magazines, or web-based information that will enhance their attendance at the course?

List of references used in creating the course.  Be sure to write these references in the proper format.  The proper professional format is the American Psychological Association Style.  Purdue University has a wonderful APA Formatting and Style Guide at

Once you have completed the above, you are ready for the next step -
 that will be writing the curriculum!  That will be our next blog installment!